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VA » Health Care » PTSD: National Center for PTSD » Providers » Acute Stress Disorder

PTSD: National Center for PTSD

Acute Stress Disorder

Acute stress disorder (ASD) is a mental health condition that captures heightened distress that takes place from 3 days to one month following trauma. Although ASD includes many of the same symptoms as posttraumatic stress disorder (PTSD), the guidelines for assessment and treatment are somewhat different. Initially the diagnosis of ASD was developed in the hopes that it would predict who would later develop PTSD, with the idea that we could then identify and treat ASD to prevent the development of PTSD. The research to date has, however, painted a more complicated picture. Because ASD has not been shown to effectively predict PTSD, there has been little significant research on ASD since the release of DSM-5 in 2013. Nevertheless, existing research gives some clinical implications for clinicians working with people who present with significant distress shortly after a traumatic event.

What is acute stress disorder (ASD)?

Similar to PTSD, ASD requires experiencing a traumatic stressor and clinically significant distress or impairment. There is also a requirement of 9 of 14 symptoms (across 4 categories: reexperiencing, dissociation, avoidance, and hyperarousal). Though there is overlap between PTSD and ASD requirements, 4 key differences are:

PTSD requires a certain number of symptoms in each symptom cluster, whereas in ASD, the 9 symptoms can come from any symptom type
PTSD includes a dissociative subtype; for ASD, dissociative symptoms are some of the core symptoms of the diagnosis
ASD does not include some of the symptoms from the PTSD negative alterations in cognitions or mood symptom cluster (e.g., negative beliefs about the self, self-blame, diminished interest or detachment)
ASD can be diagnosed from 3 days to 1 month following a trauma; PTSD is diagnosed 1 month or after

How and why has the diagnosis of acute stress disorder changed over time?

ASD was first introduced into the DSM-IV in 1994. It was in the anxiety disorders chapter and originally required at least some symptoms from each of the 4 symptom categories (dissociative, intrusive, avoidance, and arousal). ASD was kept in the DSM-5, now within the Trauma- and Stressor-Related Disorders chapter (1). The diagnosis of ASD was retained but changed between DSM versions, because there was a desire to continue to offer a diagnosis that would allow for justifying the provision of health care to people with marked distress immediately after a trauma (2). The hope that ASD would predict the development of later PTSD was not realized. No combination of symptoms adequately predicted the later development of PTSD, so the DSM-5 criteria for ASD utilize a total symptom count (2). That said, even though people do develop PTSD without initially meeting criteria for ASD, it can be helpful to identify and treat ASD because individuals with ASD are at higher risk of later developing PTSD (3). Moreover, recent research suggests that examining overall severity of ASD symptoms may help improve prediction of PTSD (4).

How common is acute stress disorder following trauma exposure?

A meta-analysis of 70 studies identified that following a traumatic event, an average of 20.4% of people will experience ASD (5). This varied by event type, with interpersonal events leading to 36.0% ASD, higher than accidents (15.9%), disasters (21.9%), war (14.1%), or life-threatening illness (20.7%). Of note, all studies used DSM-IV criteria; no DSM-5 studies met criteria for inclusion in the meta-analysis. Risk factors for developing ASD may be similar to PTSD (e.g. women and those with prior psychiatric history are more at risk), but in general, our ability to predict who will develop ASD and later PTSD is still limited (2,6).

How is acute stress disorder assessed?

The following instruments were developed for use with the DSM-IV. They have been slightly modified to apply to DSM-5 criteria, but the DSM-5 versions have not been well validated since being updated:

The Acute Stress Disorder Structured Interview – 5 (ASDI-5, 2). This interview can be used by a trained clinician and assesses for a traumatic event, the 14 DSM-5 ASD symptoms, along with items assessing distress, impairment, duration, and whether the symptoms are accounted for by other conditions.
The Acute Stress Disorder Scale-5 (ASDS-5, 2) is a 14-item self-report measure of ASD symptoms. It can be used to indicate a probable ASD diagnosis if a person scores 3 or more on at least 9 items (within 3 days to one month post-trauma).
The Stanford Acute Stress Reaction Questionnaire (SASRQ; 7) is a 30-item self-report measure of exposure to a trauma, acute stress reactions including DSM-IV ASD symptoms, and functional impairment. The measure has been translated into multiple languages (8) and preliminarily tested in a DSM-5 version (9).

How is acute stress disorder managed or treated?

The first days and weeks after a trauma may involve symptoms of distress and may also involve other immediate concerns such as finding housing after a natural disaster or managing acute physical pain after a car accident. Thus, it is possible that treatment for ASD will not be a high priority. Several considerations for management or treatment of ASD are outlined below:

Table 1. Clinical Considerations for Acute Stress Disorder Presentations

Presentation/situation	Considerations
Providing immediate resources to a group of people who have all been exposed to the same trauma	Consider offering Psychological First Aid, which has preliminary evidence among trauma-exposed individuals (10). The VA/DoD Clinical Practice Guideline (CPG) for PTSD and ASD (11, see pp. 42-43) confirms that there is insufficient evidence for any intervention—therapy or medication—when used with all who have been exposed to a trauma (12). In particular, there is no evidence to recommend the use of Critical Incident Stress Debriefing (12). There is preliminary evidence that a stepped care model can be helpful. In this model, tested in a hospital setting following injury, care managers monitor symptoms, coordinate care and provide basic behavioral activation and motivational interviewing when appropriate (13). As needed, patients received higher-intensity care—in this setting, SSRI medications or multi-session cognitive behavioral therapy (CBT). This model of care is helpful in starting with low-intensity intervention and only increasing intensity as indicated (12).
An individual has significant distress fewer than 3 days post-trauma	Distress is considered normative in the immediate aftermath of trauma. Consider consulting the VA/DoD CPG regarding acute stress reactions or combat and operational stress reactions (11, see pp. 7-8, 26-31).
An individual is more distressed by psychosocial stressors (e.g., need for shelter, managing acute pain) than trauma-related symptoms	Focus on promoting general well-being (e.g. social support, physical exercise) and addressing stressors if those are more pressing (14). Watchful waiting can be a reasonable approach to symptom management.
An individual has significant distress that has lasted more than 3 days post-trauma, and is open to treatment (with symptoms more pressing than stressors)	First, assess acute stress disorder and consider differential diagnosis (e.g. adjustment disorder, panic disorder, depression, psychosis, dissociative disorder, mTBI). If re-experiencing symptoms are prominent, the VA/DoD CPG suggests multi-session trauma-focused CBT for ASD (11, see pages 43-45; 10). This type of treatment involves generally 5 to 6, 90-minute sessions, starting with psychoeducation and anxiety management (e.g., breathing retraining). Then cognitive restructuring, imaginal and in vivo exposure can be used starting in session 2. (See the CBT for ASD manual as used in several studies, 15; 1.) If symptoms other than re-experiencing are more prominent, then consider treatment that is tailored to the symptom presentation (e.g. behavioral activation if depressive symptoms are more prominent). There is currently insufficient evidence for any pharmacotherapy to treat ASD (see pages 43-44 of the VA/DoD CPG , 11).
An individual who is already in PTSD treatment experiences a new trauma	If someone is already in treatment for PTSD, consider whether the new event is bringing up new and unrelated symptoms. If the new event is re-activating symptoms related to a prior trauma, then there may not be a need to change PTSD treatment course. If there are new symptoms, you may consider using the CBT for ASD treatment noted above.
An individual has significant distress that has lasted more than 1 month post-trauma	Assess for PTSD (and treat as appropriate).

Conclusion

Acute stress disorder was introduced into DSM-IV and revised in DSM-5 as a way to capture initial distress within the first month after a trauma. It helps identify distress, though it is not strongly predictive of who will ultimately develop PTSD. A CBT approach to treatment is indicated when someone is presenting with distress in the month after a trauma.